If yes, please state nature and duration and whether it has been completely cured

Your answer

B) Any members of your family or next of kin who has or had mental illness? *

Yes

No

How are you related

Your answer

C) Any health complications, restrictions, physical/psychological disorder that may or will affect you during your retreat? *

Yes

No

If yes, please give details.

Your answer

I hereby declare that the above information is true I am willing to abide by the meditation instructor’s advice and the Society regulations; otherwise I will leave on my own accord. I also understand that the organisers and the meditation instructor shall not be held responsible for any physical or mental injury incurred during or after attending this Retreat. *

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